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Based on record review and interview with staff, it was determined that the facility failed to have the 5 year internal inspection of the automatic sprinkler piping. Failing to conduct the 5 year internal inspection of sprinkler piping could allow build-up of foreign material which will affect the operation of the automatic sprinklers and may cause harm to patients and staff.

NFPA 101 Life Safety Code, 2012 Edition, Chapter 19, Section 19.1.1.1.3. General "The provisions of Chapter 4, General, shall apply." Chapter 4, Section 4.6.12.3, "Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed." Section 4.6.12.4, "Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. NFPA 13, "Installation of Sprinkler Systems." Chapter 26, Section 26.1, General, "A sprinkler system installed in accordance with this standard shall be properly inspected, tested and maintained by the property owner or their authorized representative in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed." NFPA 25, Chapter 14, Section 14.2 "Internal Inspection of Piping" "Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and be removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material."

Findings Include:

On April 19, 2018, the surveyor accompanied by Plant Operations Manager, reviewed the automatic sprinkler inspection, testing, and maintenance documentation which indicated that a 5 year internal inspection of the sprinkler piping was not conducted. A maintenance staff member contacted the Fire Protection Company and were told, by the company, that they were checking into the requirement.

The Chief Financial Officer and the Plant Operations Manager acknowledged during the exit conference on April 19, 2018, the automatic sprinkler inspection, testing, and maintenance documentation which indicated that a 5 year internal inspection of the sprinkler piping was not conducted.

Based on observation and interview, it was determined the facility failed to ensure that staff did not plug appliances into power strips. The use of appliances plugged into power strips could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

On April 19, 2018, the surveyor, accompanied by the Plant Operations Manager and maintenance staff, observed a refrigerator plugged into a power strip and not directly plugged in to the receptacle wall outlets, located in the Emergency Department.

The Chief Financial Officer and Plant Operations Manager acknowledged during the exit conference on April 19, 2018, a refrigerator was plugged into a power strip and not directly plugged in to the receptacle wall outlets, located in the Emergency Department.